Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-MED-48 Scrotal Ultrasound Form


scrotal ultrasound

Indications

(351507) Is the scrotal ultrasound being performed to evaluate acute scrotal symptoms (for example, pain, swelling) or trauma? 
(351508) Is the scrotal ultrasound being performed to evaluate scrotal asymmetry or enlargement (including suspected hydroceles)? 
(351509) Is the scrotal ultrasound being performed for the evaluation of scrotal masses? 
(351510) Is the procedure intended for the detection or evaluation of varicoceles? 
(351511) Is the procedure related to the evaluation of infertility? 
(351512) Is this evaluation for testicular ischemia or torsion? 
(351513) Is the patient undergoing evaluation for suspected infectious or inflammatory scrotal disease? 
(351514) Is this ultrasound being conducted to detect occult primary tumors in individuals with metastatic germ cell tumors? 

Contraindications

(351515) Is the use of scrotal ultrasound for the localization of undescended testes? 
(351516) Is the scrotal ultrasound for any condition not listed above? 
Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses the use of ultrasound imaging technologies for the evaluation of conditions affecting the scrotum and testes.

Clinical Indications

Medically Necessary:

The use of scrotal ultrasound is considered medically necessary for the following conditions:

  1. Evaluation of acute scrotal symptoms (for example, pain, swelling) and trauma; or
  2. Evaluation of scrotal asymmetry or enlargement (including suspected hydroceles); or
  3. Evaluation of scrotal masses; or
  4. Detection or evaluation of varicoceles; or
  5. Evaluation of infertility; or
  6. Evaluation of testicular ischemia or torsion; or
  7. Evaluation of suspected infectious or inflammatory scrotal disease; or
  8. Detection of occult primary tumors in individuals with metastatic germ cell tumors.

Not Medically Necessary:

The use of scrotal ultrasound is considered not medically necessary for the localization of undescended testes.

The use of scrotal ultrasound is considered not medically necessary for any condition not listed above.